Clinical research study
Post-myocardial infarction smoking cessation counseling: Associations with immediate and late mortality in older Medicare patients

https://doi.org/10.1016/j.amjmed.2004.12.007Get rights and content

Purpose

To assess the difference in immediate (30 and 60 days after admission) and late (2-year) mortality between those who received inpatient post-myocardial infarction smoking cessation counseling and those who did not receive counseling.

Methods

We conducted an observational study of a national random sample of inpatients from 2971 U.S. acute care hospitals participating in the Cooperative Cardiovascular Project in 1994–95. Medicare beneficiaries who were current smokers over age 65, admitted with a documented acute myocardial infarction, and who were discharged to home were included (n = 16 743). Our main outcome measures were early (30-, 60-day) and late (1-, 2-year) mortality.

Results

Smoking cessation counseling was documented during their index hospitalization for 41% of patients. Compared with those not counseled, those who received inpatient counseling had lower 30-day (2.0% vs. 3.0%), 60-day (3.7% vs. 5.6%), and 2-year mortality (25.0% vs. 30%) (logrank P ≪0.0001). After adjustment for demographic characteristics, comorbid conditions, APACHE score, and receipt of treatments including aspirin, reperfusion, beta-blockers, and angiotensin-converting enzyme inhibitors, those receiving counseling were less likely to die within 1 year, but the effect was lost between 1 and 2 years [hazard ratio (HR) = 0.99 (0.91–1.10)]. The greatest reduction in relative hazard (19%) was seen within 30 days [HR = 0.81 (95% confidence interval 0.65–0.99)].

Conclusion

Immediate and long-term mortality rates were lower among those receiving inpatient smoking cessation counseling.

Section snippets

Study sample and design

The CCP, a national quality improvement project funded by the Centers for Medicare and Medicaid Services (CMS), included reviews of medical records from a random sample of 234 754 Medicare patients hospitalized with myocardial infarction at 6684 hospitals in 1994 and 1995.20, 21, 22 Acute myocardial infarction cases with an International Classification of Diseases, 9th Revision, Clinical Modification 27, principal discharge diagnosis code of 410 were identified using the Medicare National Claims

Results

Of the 16 743 smokers, 41% had medical record documentation of counseling to quit smoking during their admission. Whites were more frequently counseled than African-Americans (42% vs. 34%, P ≪0.0001) (Table 1). Older patients were less frequently counseled. Surprisingly, patients with diabetes or chronic heart failure were slightly less frequently counseled and increasing severity of illness (APACHE II) was associated with lower rates of counseling.

Discussion

In our large national dataset, smokers hospitalized with acute myocardial infarction who had inpatient medical record documentation of advice to quit smoking had lower 30-day and 60-day mortality compared with those with no such documentation. After adjustment, the survival advantage decreased over time and was not apparent after 1 year.

Inpatient smoking cessation counseling has been demonstrated to improve cessation rates, especially when linked to an acute event such as an acute myocardial

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